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Medicare denials 78492

  1. #1
    Default Medicare denials 78492
    Medical Coding Books
    I have been scouring the guidlines for PET scans and there are extensive guidelines for Oncology Pets, but I keep getting denials for the Myocardial - B5 - program guidelines not met or exceeded. Can anyone offier any help?

    Thank you!

    Debra

  2. #2
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    What are the dates of services? The FDA has stopped anyone from performing any PET scans (months ago) due to a generator issue. Maybe that has something to do with your denials.

  3. #3
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    These are all early 2011. Is there a bulletin?

  4. #4
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    Quote Originally Posted by alumnieib View Post
    I have been scouring the guidlines for PET scans and there are extensive guidelines for Oncology Pets, but I keep getting denials for the Myocardial - B5 - program guidelines not met or exceeded. Can anyone offier any help?

    Thank you!

    Debra
    This is what came up under the NCD for the code you listed.

    "Item/Service Description

    The identification of patients with partial loss of heart muscle movement or hibernating myocardium is important in selecting candidates with compromised ventricular function to determine appropriateness for revascularization. Diagnostic tests such as FDG PET distinguish between dysfunctional but viable myocardial tissue and scar tissue in order to affect management decisions in patients with ischemic cardiomyopathy and left ventricular dysfunction.


    Indications and Limitations of Coverage

    1. FDG PET is covered for the determination of myocardial viability following an inconclusive single photon emission computed tomography (SPECT) test from July 1, 2001, through September 30, 2002. Only full ring PET scanners are covered from July 1, 2001, through December 31, 2001. However, as of January 1, 2002, full and partial ring scanners are covered.

    2. Beginning October 1, 2002, Medicare covers FDG PET for the determination of myocardial viability as a primary or initial diagnostic study prior to revascularization, or following an inconclusive SPECT. Studies performed by full and partial ring scanners are covered.

    Limitations: In the event a patient receives a SPECT test with inconclusive results, a PET scan may be covered. However, if a patient receives a FDG PET study with inconclusive results, a follow up SPECT test is not covered.

    Documentation that these conditions are met should be maintained by the referring physician in the beneficiary's medical record, as is normal business practice.

    (This NCD last reviewed September 2002.)"
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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